Setting up a private pay private practice?

[little_albert]

I am considering opening up a private practice in the next few years and I keep hearing/reading that accepting insurance is a nightmare and significantly negatively contributes to the lives of psychologists. It seems like a lot of people on this board -- and online in general -- advocate for a private-pay practice being the way to go. For the purposes of my question, let's say we are talking about in a large city in California.

Something I still have trouble understanding is: Who are these people that can actually afford private-pay therapy? Perhaps I am naive, but how wealthy must someone be to be able to afford $150-200 per hour? This question especially boggles me because I imagine, perhaps wrongly, that many people willing to pay this price tag are more "worried-well" type folks, not those with more severe psychopathology, who are not necessarily looking for short-term, protocol-driven, work that would lend itself to 10 sessions. Given that this might be the case, who has an extra $800 a month to throw towards 4 hours a month of "self improvement"?

I consider my family upper-middle class and most of my friends fall in the upper-middle/lower upper class, and can't think of anyone who would be able to afford this -- or who would opt for this -- over someone with a masters who takes insurance? Especially if many people don't even distinguish between psychologists and master's level therapists? This is confusing because I have also spoken to some psychologists previously (e.g., in the bay area) who tell me that all of their colleagues are booked solid with a waiting list, and only accept private pay, $200/hour+. I guess this makes sense if their clients were all working in tech, but what about other areas of CA, like Southern California?

For those of you who have worked with private pay clients, who are these people? How wealthy are they actually? What has been your experience doing therapy with them? How long do they typically stay? Are they more inclined to pay for child/adolescent therapy over therapy for themselves? Or are they more likely to pay PP for couples therapy because their relationship is in shambles? Do they tend to be more entitled/rude? So many questions about this sub-population I have gotten little exposure to. Reflecting about all this makes me realize the vast majority of my work has been with lower SES people.

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[Sanman]

I'm not going to get into a comprehensive review of who goes to see psychologists for private pay as this is a broad question and one that gets into business planning. However, I point a couple of flaws in your thought process. First, not everyone has insurance access to a psychotherapist. Many have high deductible/ HSA driven plans that a fee-for-service psychologist can be paid through. some can submit claims out-of-network to insurance themselves for partial reimbursement, and some don't want treatment on the record with insurance.

 

[AbnormalPsych]

Definitely second the "off the record" folks, for a variety of reasons.

In my old town I know that a lot of the "good" clinicians were only private pay - because they could be. From $125/hr on up with full schedules.

Also, people really do value their (mental) health. At that rate, and sometimes even greater. I know if I had a medical dx that needed treatment, I wouldn't hesitate for a second to be treated at a couple hundred dollars/hr. Mental health care is the same for many folks. At the end of the day we do provide valuable health care.

 

[foreverbull]

I see folks in PP who are generally middle-class who can't afford weekly therapy but value self-work enough to make some sacrifices and see me 2x/month. Most of my current clients can't afford weekly therapy at my rate, but will see me long term every other week. Occasionally I get a client who can come weekly. These folks are generally not "worried well" but fairly depressed or have severe anxiety. The "adjustment/exploration" folks are few and far between.

The reality for many is to offer sliding fee scales that go down to a certain level you're comfortable with in my area.

In a nearby town that's more upper middle class, lots of folks can afford the heavy price tag, but it's heavily saturated as a result and the office rentals are much more expensive.

Once you build enough of a reputation, folks will pay your fee, but like I said, if in a middle-class area, 2x/month is common as well as sliding fee scales for folks who can't afford $150+. Not taking insurance definitely slows growth for a long while; I've turned away 10+ prospective clients due to not taking insurance and they can't afford my fee. I need almost double the clients to have weekly spots filled.

Also keep in mind that almost everyone wants the 3pm and 4pm slots or later. Early career colleagues and I have trouble filling up mornings or early afternoons.

 

[PsyDr]

With all due respect, you're making the classic error of assuming your experience is data. You know that's not how this works. You should really educate yourself about the finances of your region. This is business plan 101 for any business plan. With all due respect, you're probably not in the upper middle class, at least by income.

1) play around with this, but be aware that the calculator isn't great. I can get upper 15% by using any of these numbers 90, 150, 250, 400k, 500k, etc: Are you in the American middle class? Find out with our income calculator

2) Story: I once dated a woman whose parents made around $50k/yr/each. She had a successful brother who made around $650k. When I pointed out that his monthly paycheck was equal to a year's worth of her fathers, she had a hard time wrapping her head about this. That income doesn't even make you in the top 5% in my city.

 

[WisNeuro]

Woohoo, I'm in the Upper Income tier!

 

[Justanothergrad]

Woohoo, I'm in the Upper Income tier!

Boy have I got a good deal for you- a real once in the life time investment opportunity!

 

[WisNeuro]

Boy have I got a good deal for you- a real once in the life time investment opportunity!

I already shuffle about 25% of my income to retirement/investments. With some occasional frivolous investments for fun. Bought into a brewery this past year.

 

[Justanothergrad]

I already shuffle about 25% of my income to retirement/investments. With some occasional frivolous investments for fun. Bought into a brewery this past year.

Ditto. It's amazing how many people are shocked to hear me tell them I put 25% of my income away each month into retirement. Buying into a brewery seems like a good/fun investment. I need to diversify investments in the next 2-3 years to get into some local business ventures and such but I want to get past my first year out to solidify other life investments first.

 

[Sanman]

I think we are an odd group as I save a similar percentage of my income as does my wife.

As to people being able to afford cash sessions, I once listened to a woman complain about my $60 cash fee for seeing her dtr with severe behavioral issues while also complaining that said teenage daughter urinated in her brand new Cadillac SUV prior to the session. How much is that lease? Priorities are different for everyone.

 

[foreverbull]

OP, feel free to PM me if you want more specifics since you seem to be in a similar area.

 

[Therapist4Chnge]

I already shuffle about 25% of my income to retirement/investments. With some occasional frivolous investments for fun. Bought into a brewery this past year.

Soooo....when are we doing a sampling?

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As for cash pay patients....I doubt people will freely share that info because it was hard earned and/or paid for through consultation with someone who’s done it before.

I don’t accept insurance and keep a mix of clinical and legal work. It takes a lot of networking, marketing, and positioning yourself in the right market(s). This is all consultation and eval, so YMMV with actual treatment.

 

[smalltownpsych]

Woohoo, I'm in the Upper Income tier!

Me too!

 

[little_albert]

I'm not going to get into a comprehensive review of who goes to see psychologists for private pay as this is a broad question and one that gets into business planning. However, I point a couple of flaws in your thought process. First, not everyone has insurance access to a psychotherapist. Many have high deductible/ HSA driven plans that a fee-for-service psychologist can be paid through. some can submit claims out-of-network to insurance themselves for partial reimbursement, and some don't want treatment on the record with insurance.

Soooo....when are we doing a sampling?

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As for cash pay patients....I doubt people will freely share that info because it was hard earned and/or paid for through consultation with someone who’s done it before.

I don’t accept insurance and keep a mix of clinical and legal work. It takes a lot of networking, marketing, and positioning yourself in the right market(s). This is all consultation and eval, so YMMV with actual treatment.

To be fair, the purpose of my question was not so much to ask "how do I get PP clients or build a PP practice". Sorry if I gave that impression with the questions I listed. Like I said I am still a few years away from building a practice (insurance or not) for the first time. I am more so curious who the population is in general who can pay for out of pocket therapy (broadly) and what have been your experiences working with said clients (pos/neg,etc). I appreciate your responses.

@Sanman thanks for that helpful info! Those are good points and i've never considered clients with those types of insurance plans. I also don't know much about how submitting claims for out-of-network providers works -- or what % of clients actually do this vs. just paying PP with a sliding scale.

Definitely not trying to be greedy or data mine information anyone had to seek professional consultation for, but would be appreciative and grateful of a 'road map' so to speak, of your impressions of what types of clients seek PP over insurance.

 

[little_albert]

OP, feel free to PM me if you want more specifics since you seem to be in a similar area.

Sounds good! PM'ing you

 

[DynamicDidactic]

Bought into a brewery this past year.

Interesting, I am guessing a small local brewery? Its a very unpredictable time for craft beer right now. Way off topic but a big interest of mine.

 

[WisNeuro]

Interesting, I am guessing a small local brewery? Its a very unpredictable time for craft beer right now. Way off topic but a big interest of mine.

Yes, local thing, just a few shares. Although, the perks (free pints in the taproom) will likely pay off before the dividends do.

 

[little_albert]

Not to monopolize the conversation and steer it away from craft brews (to which I am a fan, ha), but anyone else care to share their insights on working with PP clients (even if non-trade secrets)? Sanman, AbnormalPsych, Therapist4Chnge, et al?

 

[Peacemaker36]

I would keep in mind that when it comes to self-pay, the neuropsych and psychotherapy universes are quite different.

In the psychotherapy realm, it helps to have any of the following: a doctorate, affiliations, a niche, referral streams, ability to work with child/adolescents, and/or practice in an area with low saturation (or high saturation of wealthy people).

 

[AbnormalPsych]

Yes, local thing, just a few shares. Although, the perks (free pints in the taproom) will likely pay off before the dividends do.

Craft brews are the best. I am genuinely interested in this investment as well.

Not to monopolize the conversation and steer it away from craft brews (to which I am a fan, ha), but anyone else care to share their insights on working with PP clients (even if non-trade secrets)? Sanman, AbnormalPsych, Therapist4Chnge, et al?

I would keep in mind that when it comes to self-pay, the neuropsych and psychotherapy universes are quite different.

In the psychotherapy realm, it helps to have any of the following: a doctorate, affiliations, a niche, referral streams, ability to work with child/adolescents, and/or practice in an area with low saturation (or high saturation of wealthy people).

Yep, this is pretty much consistent with my experience in this area. I also see people taking cash more frequently for assessment services than therapy, but that may just be that I have been around a lot more assessment people in PP. Regarding therapy, the folks I have seen take cash tend to be more psychodynamic, have a very specific niche, and aren't treating w/manuals, doing super short-term work, or treating SMI. They often also do a ton of work upfront the establish themselves and build relationships (e.g., free talks, volunteer work, be a well-respected prof at the local Uni). I'm sure some of this may just be the towns I have been in as well and may not generalize.

 

[smalltownpsych]

One good tip is that in order to succeed in private practice you have to be effective. The skills needed are ability to develop rapport quickly, formulate a treatment plan rapidly, provide immediate benefit. You have to provide a higher level of service for cash pay customers. Most people won't waste money on something that is not working so they will want to see some progress. Not in the form of B.S. measurable goals the way that some agencies demand either. The gains need to be qualitative. If you are working with kids or adolescents then frequent contact with parents and providing coaching and family sessions is essential.

 

[artsyann]

I will say once we found a greatness provider for my child who took insurance we stopped with the private pay one. She was great but her fee was $135 for a 30 min appt. It severely limited how often we could go. I know people around here may do it for off the records reasons, but in my area that is mainly for child psychologists and psychiatrists.

 

[little_albert]

One good tip is that in order to succeed in private practice you have to be effective. The skills needed are ability to develop rapport quickly, formulate a treatment plan rapidly, provide immediate benefit. You have to provide a higher level of service for cash pay customers. Most people won't waste money on something that is not working so they will want to see some progress. Not in the form of B.S. measurable goals the way that some agencies demand either. The gains need to be qualitative. If you are working with kids or adolescents then frequent contact with parents and providing coaching and family sessions is essential.

When you say B.S. measurable goals, what are you referring to? Something I have noticed working the last year with adolescents (for the first time) is that their scores on depression/anxiety do not seem to match how they are doing sometimes. That is, when I have an adult with a BDI* of 30+, usually they look/seem really depressed and are showing significant impairment in their lives. Conversely, it seems like a lot of the teens I see have scores that are off the charts but they seem only mildly depressed. I'm obviously not a peds expert, but I find the difference fascinating. It can seem almost histrionic! For example, sometimes the parent doesn't even know the teen is depressed and are surprised to hear their kid scored off the charts. I would like to use a Psychotherapy Outcome Monitoring system in my practice some day, but would be cautious to use it with young teens as they appear to exaggerate their symptoms at times....or maybe it's just the teens i've been seeing? By qualitative do you just mean that the kids are acting happier to parents/in school, etc, vs what more objective measures are saying?

*This is probably what I get for administering adult batteries to teens (16-18) instead of peds measures, as they aren't normed for them.

 

[futureapppsy2]

*This is probably what I get for administering adult batteries to teens instead of peds measures, as they aren't normed for them.

Uh, yeah, that’s definitely a massive issue...

 

[Therapist4Chnge]

Not to monopolize the conversation and steer it away from craft brews (to which I am a fan, ha), but anyone else care to share their insights on working with PP clients (even if non-trade secrets)? Sanman, AbnormalPsych, Therapist4Chnge, et al?

1. Have a defined niche. It doesn't have to be the only cases you see, but you don’t want to be a jack of all trades and master of none. Being fellowship trained and hopefully boarded helps w carving out a niche.

2. Be responsive. If someone is paying cash they expect better responsiveness. Referrals who send you cash patients should also be treated like gold bc it’s hard to find a consistent stream of cash pay patients in most areas.

3. It’ll likely take you at least a year and likely more to be consistently busy. In the beginning expect to spend a lot of time (and some $$) networking. This includes bringing offices coffee/lunch, taking ppl out to dinner, speaking (for free) at events, etc. It goes both ways, but many times providers quickly forget to continue to go the extra mile. I call providers every few weeks if I have ongoing cases with them. I also have taken some challenging cases I normally would pass on bc it came from a solid referral source.

 

[LadyHalcyon]

When you say B.S. measurable goals, what are you referring to? Something I have noticed working the last year with adolescents (for the first time) is that their scores on depression/anxiety do not seem to match how they are doing sometimes. That is, when I have an adult with a BDI* of 30+, usually they look/seem really depressed and are showing significant impairment in their lives. Conversely, it seems like a lot of the teens I see have scores that are off the charts but they seem only mildly depressed. I'm obviously not a peds expert, but I find the difference fascinating. It can seem almost histrionic! For example, sometimes the parent doesn't even know the teen is depressed and are surprised to hear their kid scored off the charts. I would like to use a Psychotherapy Outcome Monitoring system in my practice some day, but would be cautious to use it with young teens as they appear to exaggerate their symptoms at times....or maybe it's just the teens i've been seeing? By qualitative do you just mean that the kids are acting happier to parents/in school, etc, vs what more objective measures are saying?

*This is probably what I get for administering adult batteries to teens (16-18) instead of peds measures, as they aren't normed for them.

Why would you use a test with a population it shouldn't be used with?

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[smalltownpsych]

When you say B.S. measurable goals, what are you referring to? Something I have noticed working the last year with adolescents (for the first time) is that their scores on depression/anxiety do not seem to match how they are doing sometimes. That is, when I have an adult with a BDI* of 30+, usually they look/seem really depressed and are showing significant impairment in their lives. Conversely, it seems like a lot of the teens I see have scores that are off the charts but they seem only mildly depressed. I'm obviously not a peds expert, but I find the difference fascinating. It can seem almost histrionic! For example, sometimes the parent doesn't even know the teen is depressed and are surprised to hear their kid scored off the charts. I would like to use a Psychotherapy Outcome Monitoring system in my practice some day, but would be cautious to use it with young teens as they appear to exaggerate their symptoms at times....or maybe it's just the teens i've been seeing? By qualitative do you just mean that the kids are acting happier to parents/in school, etc, vs what more objective measures are saying?

*This is probably what I get for administering adult batteries to teens (16-18) instead of peds measures, as they aren't normed for them.

I wasn't referring to screening devices specifically which can have some utility, but I don't know if I would use them in a private practice setting because I tend to observe the patients apparent emotional state, comment on it, and then ask how they are doing. Self-harm, suicidal ideation, impulsive behavior, emotional regulation, negative thoughts, depressed mood. These are some of the things that I work with my patients on and I really believe that it is more helpful to treat them as qualitative than to try to convert them to quantitative. It can be fine and make sense for research, but it won't go far in the private pay world to spend much time doing that. Then there is the trap of making progress on the goals, but still justifying treatment. Argh!

 

[medium rare]

I have been in a cash private practice for 9 years. As has been mentioned previously, having a niche is very helpful even if you do other types of clinical work. It does take longer to build but if you are not generating a consistent revenue stream within 6 months, you are doing something wrong.

The biggest mistake I observe with failed practices is not thinking of a practice as a business first and foremost. A business mindset is quite different than a clinical one and if you can’t manage both, you will not be successful.

The majority of my patients are middle class. I do have wealthy patients but they are not the modal patient. People value mental health services and they will and do pay for quality. Having prescriptive authority helped fill my practice quickly (and keeps me fully booked with a wait list) but it is not necessary to be successful in a self-pay practice. I share an office suite with three other psychologists and a PMHNP. None of them take insurance and they all have full schedules and do very well financially.

 

[Sanman]

I have been in a cash private practice for 9 years. As has been mentioned previously, having a niche is very helpful even if you do other types of clinical work. It does take longer to build but if you are not generating a consistent revenue stream within 6 months, you are doing something wrong.

The biggest mistake I observe with failed practices is not thinking of a practice as a business first and foremost. A business mindset is quite different than a clinical one and if you can’t manage both, you will not be successful.

The majority of my patients are middle class. I do have wealthy patients but they are not the modal patient. People value mental health services and they will and do pay for quality. Having prescriptive authority helped fill my practice quickly (and keeps me fully booked with a wait list) but it is not necessary to be successful in a self-pay practice. I share an office suite with three other psychologists and a PMHNP. None of them take insurance and they all have full schedules and do very well financially.

Out of curiosity, are all of the people you share a practice with prescribers as well?

 

[medium rare]

Out of curiosity, are all of the people you share a practice with prescribers as well?

No. There is a PMHNP in my suite who’s there one day/week. The three psychologists are full-time and do not have prescriptive authority.

 

[little_albert]

I have been in a cash private practice for 9 years. As has been mentioned previously, having a niche is very helpful even if you do other types of clinical work. It does take longer to build but if you are not generating a consistent revenue stream within 6 months, you are doing something wrong.

The biggest mistake I observe with failed practices is not thinking of a practice as a business first and foremost. A business mindset is quite different than a clinical one and if you can’t manage both, you will not be successful.

The majority of my patients are middle class. I do have wealthy patients but they are not the modal patient. People value mental health services and they will and do pay for quality. Having prescriptive authority helped fill my practice quickly (and keeps me fully booked with a wait list) but it is not necessary to be successful in a self-pay practice. I share an office suite with three other psychologists and a PMHNP. None of them take insurance and they all have full schedules and do very well financially.

Thank you for the useful info! Congrats on the successful practice. Just out of curiosity, if you don't mind sharing, how specific of a niche are we talking about? Like, a fairly general niche of working with children / adolescents or providing couples therapy, or something more specific like the treatment of OCD or PTSD? One concern I had about choosing too specific a niche (e.g., a specific disorder or two) is that the practice might be hard to fill given that the low prevalence of some of these disorders. Maybe you could give some examples of what kind of niches the other psychologists in your practice have -- or you have seen?

 

[medium rare]

Thank you for the useful info! Congrats on the successful practice. Just out of curiosity, if you don't mind sharing, how specific of a niche are we talking about? Like, a fairly general niche of working with children / adolescents or providing couples therapy, or something more specific like the treatment of OCD or PTSD? One concern I had about choosing too specific a niche (e.g., a specific disorder or two) is that the practice might be hard to fill given that the low prevalence of some of these disorders. Maybe you could give some examples of what kind of niches the other psychologists in your practice have -- or you have seen?

An area of practice that is specific enough for others in the community to think of you when making referrals and something you enjoy doing. Being known for working with certain populations and/or certain disorders is helpful but it doesn’t necessarily have to limit what you do clinically.

I have specialized training with the child/adolescent population and focus on the integration of psychotherapy and medication. Many people seek me out specifically for this. However, about 40% of my practice is with adults as I also have a reputation as someone who can treat complex cases and I get numerous referrals from other therapists as well as pediatricians, internists, family medicine, ob/gyn, neurologists, neuropsychologists, NPs/PAs and schools. I also get several referrals from psychiatrists as well as attorneys.

Having a focus area that you are known for helps generate consistent referrals and helps get you established but you can still do other kinds of work as you become more selective in your practice.

The other psychologists in my suite specialize in adolescents, eating disorders, anxiety and OCD, autism spectrum disorders and couples therapy as niches but each of them has a relatively diverse clinical practice.

 

[ClinicalABA]

You have to provide a higher level of service for cash pay customers.

Interesting statement. I see almost exclusively Medicaid participants and was not aware that I could provide them anything but my best level of service. Now that I know, I’m going in late today and am going to play legos for two hours instead of doing that pesky empirically validated stuff that I typically do. Maybe I’ll even cut the session short and grab an early lunch!

I know that’s not what you meant (at least I hope so), but the implications of that statement are, imho, pretty bleak.

 

[WisNeuro]

I know that’s not what you meant (at least I hope so), but the implications of that statement are, imho, pretty bleak.

My take on it was that you put up with certain kinds of bull****e that you otherwise would not. Gots to keep the high paying cash patients and the referral sources happy.

 

[ClinicalABA]

My take on it was that you put up with certain kinds of bull****e that you otherwise would not. Gots to keep the high paying cash patients and the referral sources happy.

Of course- I get that part of it. However, failure to provide medicaid funded chidren with the same high level of care led to a class action lawsuit in my state. I gues my argument would be that you should provide only one level of service- i.e., the BEST that you can. If you can't do that, either don't accept the client (my first preference) or be sure to inform them at the outset (such as in your consent paperwork) that, because of their funding source, they will be getting less than your best (and see how long you remain panelled).

 

[WisNeuro]

Of course- I get that part of it. However, failure to provide medicaid funded chidren with the same high level of care led to a class action lawsuit in my state. I gues my argument would be that you should provide only one level of service- i.e., the BEST that you can. If you can't do that, either don't accept the client (my first preference) or be sure to inform them at the outset (such as in your consent paperwork) that, because of their funding source, they will be getting less than your best (and see how long you remain panelled).

I slightly disagree. I mean, you should always provide the same level of clinical service, hands down. But, if I'm getting 100/hr from Medicare for a patient vs 3-400 from a private pay patient, there are non-clinical customer service things that will likely be different. Just the way that things work. Don't go that extra mile for BS things and watch your private pay referrals dwindle.

 

[smalltownpsych]

Interesting statement. I see almost exclusively Medicaid participants and was not aware that I could provide them anything but my best level of service. Now that I know, I’m going in late today and am going to play legos for two hours instead of doing that pesky empirically validated stuff that I typically do. Maybe I’ll even cut the session short and grab an early lunch!

I know that’s not what you meant (at least I hope so), but the implications of that statement are, imho, pretty bleak.

Definitely not what I meant. I have worked in both settings and my treatment is the same in either setting. When the patient(s) is in the room, I really don't think about financial stuff other than how it actually impacts the patient. I was referring more to the actual limitations on treatment or "extra" services.
For example, our medicaid program just put a limit of ten sessions per year for kids. Also, length of stay at inpatient or residential facilities is much different. 30 days is about the most I can get for a kid with insurance and the place that I am going to be working at in a couple of months has an average length of stay of 18 months. It also is a much higher quality program than any of the governmental or quasi-governmental agencies and once I start working there it will be even better. It probably helps that the two top guys will be a psychiatrist who owns it and a psychologist to supervise everyone. Unfortunately, a lot of programs that I have seen do not have doctoral level clinicians with solid leadership skills in key positions. In the past when I have looked at clinical director jobs, they were asking for MA level folks and paying 60k a year.

The other point that I was alluding to is that poor clinicians can often hide better in an agency than they can in a private-pay setting. So it's not that the clinician is varying what they provide as opposed to a varying quality of the actual clinician. Something along the lines of "you get what you pay for". Not always the case, I have seen some better charlatans or snake-oil salesmen in the private-pay world too so there is that.

 

[ClinicalABA]

Definitely not what I meant.

I didn't think so! It's certainly an important message that if you want to attract people with options (e.g. private pay clients), you can't suck! I think it's an important add-on message that even if you work with people without options, you shouldn't suck!

...and once I start working there it will be even better.

Yeah it will!!

It can definitely get tricky. It's a good rule to be sure to get paid for what you do and do what you get paid for. Fortunately for me, our medicaid program (MassHealth) is pretty good regarding what they'll cover and relatively easy to work with as a provider (e.g., simple testing auth form). I can totally understand offering higher quality non-clinical related services to private pay clients. It still bothers me to think that, when it comes to mental health treatment, there can be such disparity and the Medicaid clients are on months-long waitlists to see poorly trained (and paid) psychs and mid-levels and underfunded CMHCs.

 

[smalltownpsych]

I didn't think so! It's certainly an important message that if you want to attract people with options (e.g. private pay clients), you can't suck! I think it's an important add-on message that even if you work with people without options, you shouldn't suck!

Well said and so much more succinct than what I wrote. Sometimes I can get a bit wordy and lose my whole point. One of the big things that I have had to work on both in my previous occupation in sales and my current occupation as a therapist was to not talk too damn much. Good advice for any of us is to keep it short and sweet.

It can definitely get tricky. It's a good rule to be sure to get paid for what you do and do what you get paid for. Fortunately for me, our medicaid program (MassHealth) is pretty good regarding what they'll cover and relatively easy to work with as a provider (e.g., simple testing auth form). I can totally understand offering higher quality non-clinical related services to private pay clients. It still bothers me to think that, when it comes to mental health treatment, there can be such disparity and the Medicaid clients are on months-long waitlists to see poorly trained (and paid) psychs and mid-levels and underfunded CMHCs.

I have never had an administrative role in a mental health agency that was not private pay, mainly because I haven't had the opportunity. My CV apparently speaks more to the private pay world or maybe they just don't pay enough. The place i did my post-doc was a CMHC that was run by a MSW that had been doing it for 20 years and was being paid 70k a year. He sort of reminded me of this guy from Dances with Wolves - a little too much time on the frontier.

I used to have a potential goal of going into the publicly funded treatment world and work on attempting to bring a higher level of care to it. Just don't know if I could, should, or would at this point in my career.

 

[PsyDr]

I think what you, my illustrious and learned colleagues, are attempting to describe is the difference between a community standard of care and gold standard of care using the definition which reflects “best possible care”.

 

[smalltownpsych]

I think what you, my illustrious and learned colleagues, are attempting to describe is the difference between a community standard of care and gold standard of care using the definition which reflects “best possible care”.

On the other hand, one could argue that much community standard of care is pretty low. One aspect of the agency that I will be working at is to save young adults with serious mental health problems from the negative effects of the community-based system. Unfortunately there isn't much in the middle.

 

[PsyDr]

On the other hand, one could argue that much community standard of care is pretty low. One aspect of the agency that I will be working at is to save young adults with serious mental health problems from the negative effects of the community-based system. Unfortunately there isn't much in the middle.

Community standard of care is a legal definition and refers to the reasonable psychological practices of a given area. This is not an average of the practices of the community because that would include the unreasonable.

 

[Sanman]

Interesting statement. I see almost exclusively Medicaid participants and was not aware that I could provide them anything but my best level of service. Now that I know, I’m going in late today and am going to play legos for two hours instead of doing that pesky empirically validated stuff that I typically do. Maybe I’ll even cut the session short and grab an early lunch!

I know that’s not what you meant (at least I hope so), but the implications of that statement are, imho, pretty bleak.

I will emphasize the difference in difference PSYDR pointed out. I provide community standard of care to everyone and best possible care when I can. However, the idea that I gave the gold standard to medicaid patients is unrealistic. Even working on salary in a private practice environment, there was a push see more patients if you see medicaid patients were seen. I don't believe that we even billed for them. There are X number of hours in a day and the more patients I see, the less time I have for researching, tailoring treatments, etc. That is just reality. I can always do more if I have more time and resources, it is a balance.

Frankly, I find it silly that healthcare as an industry tries to take the position that money does not matter at times. That would not fly in any other type of business environment (and healthcare is a business in the U.S.; not a social program as I hope it would be at times) and doesn't really work in this industry either. Burnout and other issues plague mental health agencies that deal with medicaid patients and poor clinical practices abound. The rationing of care comes in ways that we do not even count. Can you imagine the response if I walked into a Motel 6 and asked why there was not any room service or a bellhop?

 

[WisNeuro]

Frankly, I find it silly that healthcare as an industry tries to take the position that money does not matter at times. That would not fly in any other type of business environment (and healthcare is a business in the U.S.; not a social program as I hope it would be at times) and doesn't really work in this industry either. Burnout and other issues plague mental health agencies that deal with medicaid patients and poor clinical practices abound. The rationing of care comes in ways that we do not even count. Can you imagine the response if I walked into a Motel 6 and asked why there was not any room service or a bellhop?

Additionally, sometimes the compensation does not allow us to even give what is considered the community standard of care. For example, in the state next to us, of which we are close enough to get patients from, the state managed Medicaid plans give us a total of 6 hours for an evaluation. That 6 hours includes chart review, interview, testing, scoring, interpretation, report writing, and feedback. That's uh, not a lot of time. In addition, they pay about $40/hour for these services. So, you do the math. We essentially limit these evals to once a month, at most, and just treat it as pro bono work for the most part. So yeah, money plays a big role in certain aspects. If you want it to change, run for Congress. But, I'm not working 60 hours a week, or taking a huge pay cut to provide charity. Not at this stage in my life.

I'm salary, so these don't affect me too much. But, if I go to a production model, or if I was private practice (no insurance) these individuals would not be scheduled into my clinic.